Abstract
目的
探讨血管内超声（IVUS）指导下冠脉旋磨术（RA）联合切割球囊（CB）预处理冠状动脉重度钙化病变的的疗效及安全性。
方法
2016年1月~2019年1月在我院选取经IVUS检查出冠状动脉重度钙化病变且需行冠脉介入（PCI）的患者120例。按照数字表法随机分为两组，在PCI前分别给予不同的预处理方案：SB组[RA+普通半顺应性球囊（SB），60例]和CB组（RA+CB，60例）。预处理后均置入药物洗脱支架。比较两组患者的即刻PCI成功率、PCI术后IVUS检测指标（最小支架内管腔直径、最小支架内管腔横截面积、管腔横截面积残余狭窄程度、即刻管腔直径获得、即刻管腔横截面积获得），统计病变残余狭窄 < 10%的优良率，随访术中并发症及术后24月主要不良心脏事件（MACE）。
结果
CB组患者的手术即刻成功率高于SB组（P=0.032）；预处理及支架置入后，CB组患者的最小支架内管腔直径（P=0.035）、最小支架内管腔横截面积（P=0.029）、即刻管腔获得、即刻管腔横截面积获得及病变残余狭窄 < 10 %的优良率均明显大于SB组（P＜0.001），CB组患者的管腔横截面积残余狭窄程度轻于SB组（χ2=7.859，P=0.005）；CB组患者的术中并发症发生率（χ2=5.997，P=0.014）及术后24月MACE发生率均低于SB组（χ2=4.285，P=0.038）。
结论
对适合PCI的冠状动脉重度钙化病变实施RA+CB，可明显提高即刻PCI成功率，扩大PCI术后支架内管腔直径及横截面积，即刻管腔获得显著，降低术中并发症及术后24个月MACE发生率，改善患者预后。
Keywords: 冠状动脉钙化, 旋磨术, 切割球囊, 半顺应性球囊, 血管内超声
Abstract
Objective
To investigate the efficacy and safety of intravascular ultrasound (IVUS)-guided rotational atherectomy (RA) combined with cutting balloon for pretreatment of severe calcified lesions in the coronary artery before stent placement.
Methods
A total of 120 patients with severe coronary artery calcifications detected by IVUS that required percutaneous coronary intervention (PCI) were recruited from our hospital between January, 2016 to January, 2019. The patients were randomized into two groups for pretreatment of the lesions with semicompliant balloon (SB group, 60 cases) or RA combined with CB (RA+CB group, 60 cases), and drug-eluting stents were implanted after the procedure. The immediate success rate of PCI, vascular parameters detected by IVUS after PCI, and the rates of residual stenosis < 10% were compared between the two groups. The incidences of intraoperative complications and major adverse cardiac events (MACE) within 24 months after the surgery were also observed in the two groups.
Results
The immediate success rate was significantly higher in RA+CB group than in SB group (P=0.032). After pretreatment and stent placement, the minimum stent lumen diameter (P=0.035), minimum stent lumen cross-sectional area (P=0.029), immediate lumen acquisition, immediate lumen cross-sectional area acquisition and the rate of residual stenosis < 10% were all significantly higher in RA+CB group than in SB group (P < 0.001). The patients in RA+ CB group showed obviously less residual stenosis of lumen cross-sectional area than those in SB group after the surgery (χ2= 7.859, P=0.005). The incidences of intraoperative complications (χ2=5.997, P=0.014) and MACE within 24 months after the operation (χ2=4.285, P=0.038) were significantly lower in RA+CB group than in SB group.
Conclusion
For patients with severe coronary artery calcifications eligible for PCI, RA combined with CB angioplasty can significantly improve the success rate of immediate PCI, expand the lumen diameter and cross-sectional area of the stent after PCI, enhance immediate lumen gain, and reduce the incidence of intraoperative complications and MACE after the operation.
Keywords: coronary artery calcification, rotational atherectomy, cutting balloon, semicompliant balloon, intravascular ultrasound
随着经皮冠状动脉介入治疗（PCI）患者例数逐年增多，需要治疗的复杂病变也日益增多，而冠状动脉内膜重度钙化病变目前仍是PCI领域的一大挑战[1]。冠状动脉内膜重度钙化属于高阻力病变，常引起球囊和支架不能通过，球囊扩张时难以充分扩张，增加扩张压力易造成血管夹层、穿孔[2]。置入支架时易出现支架膨胀不全、支架脱载、导丝断裂、支架不规则变形、贴壁不良，增加了支架纵向压缩、导丝断裂、支架脱落等风险，降低了手术成功率，导致远期支架内血栓和再狭窄发生率增高[3]，已成为介入过程中的瓶颈。因此，临床上常在介入前对冠状动脉重度钙化病变进行充分的预处理，即斑块修饰[4]。常用冠状动脉旋磨术（RA）联合切割球囊（CB）预扩张，或RA联合普通半顺应性球囊（SB）预扩张[5]。SB预扩张因其应用已久，技术成熟，且成本廉价等优点，目前仍有应用于RA后预扩张。RA+CB与RA+SB，对于重度钙化病变哪种RA后预处理方案更为有效，对此的临床研究报道较少。李其勇等[6]的研究表明，RA+CB的即刻管腔获得更加明显，安全性良好，但其研究的样本量太少，随访时间较短（术后12月）。本研究在血管内超声（IVUS）指导下采用前瞻性随机对照研究，增加了样本量，延长随访时间为24月，更进一步比较两种预处理方案的疗效及安全性。
1. 资料和方法
1.1. 研究对象
2016年1月~2019年1月在焦作市人民医院心内科病房，选择冠状动脉内膜重度钙化病变且需行PCI治疗的不稳定性心绞痛患者120例。入选标准：（1）符合2007年中华医学会心血管病学分会制定《不稳定性心绞痛和非ST段抬高心肌梗死诊断与治疗指南》中不稳定性心绞痛的诊断标准[7]；（2）先经冠状动脉计算机断层扫描检查，评估冠状动脉Agatston钙化积分>400 [8, 9]；（3）再经IVUS检查显示沿血管壁分布强回声光团伴声影，内膜最大钙化弧度>270°，明确为冠状动脉内膜重度钙化（Ⅳ级）病变，且为冠状动脉重度狭窄，即缺血相关冠脉血管狭窄>70%，符合旋磨术的适应症；（4）合并糖尿病、高血压，要求近2个月内血糖、血压均控制达标；（5）患者签署知情同意书，并配合随访至术后24个月。排除标准：（1）靶病变为溃疡性、血栓性或完全闭塞病变，旋磨可加重血栓倾向；（2）极度弯曲的成角病变（>60°）；（3）退行性变的大隐静脉桥病变，旋磨易发生血栓栓塞或无复流现象；（4）有明显内膜撕裂病变，尤其是螺旋形内膜撕裂，旋磨可使撕裂加重；（5）经皮冠状动脉导丝无法通过的闭塞性病变；（6）左心室射血分数 < 30 %；（7）合并恶性肿瘤、血液系统疾病、自身免疫性疾病、周围血管性疾病、严重器官（肺、肝、肾）功能不全；（8）有PCI的其他禁忌证。本研究经医院医学伦理委员会审核批准。
1.2. 治疗方法
所有患者均于术前及术后24月常规应用双联抗血小板聚集药物（阿司匹林、氯吡格雷或替格瑞洛）。术中常规应用普通肝素70~100 U/kg，维持激活凝血时间>300 s。PCI中采用RotablatorTM冠脉内旋磨治疗仪（美国波士顿）。依据IVUS检测的参考血管直径从小到大依次选用直径1.25、1.50、1.75、2.0 mm的旋磨头，旋磨头/血管直径比为0.5~0.6 [10]。将选好的旋磨头沿旋磨导丝轻轻推送到导管开口处，缓慢推送旋磨头接触钙化斑块。旋磨时旋磨头转速为140 000~180 000 r/min，控制转速骤升骤降幅度 < 5000 r/min [11]。每次旋磨时间持续15~20 s，两次间隔20 s。每处病变旋磨2~3次，如经3次旋磨仍不能通过钙化病变则逐渐升高旋磨转速。旋磨同时经旋磨系统持续加压（150~200 mm Hg）灌注冲洗旋磨导管，以冷却润滑旋磨头。灌注冲洗液包含：肝素5000 U+硝酸甘油2 mg+维拉帕米2.5 mg+ 500 mL生理盐水[12]。完毕迅速退出旋磨头至病变近端，回撤时旋磨转速采用低速60 000~90 000 r/min。旋磨成功后，SB组先常规应用SB扩张，CB组先行CB扩张。随后两组均再采用常规方法置入雷帕霉素药物洗脱支架。两组均依据血管直径大小选择球囊，一般选择直径小于参照血管直径0.5 mm的球囊为宜。即刻PCI成功定义为支架贴壁良好、扩张充分、展开均匀以及完全覆盖病变区域，支架置入后局部残余狭窄 < 20%，靶病变处无夹层、血栓、穿孔等，冠状动脉心肌梗死溶栓（TIMI）血流分级Ⅲ级[13]。常规给予他汀类调脂、控制血压、控制血糖、抗凝等冠心病二级预防药物治疗。
1.3. 观察指标
1.3.1. 血管内超声指标
术前术后应用IVUS系统（波士顿）检测，探头频率40 MHz。经指引导管将0.014 in（0.3556 mm）指引导丝置入待检血管，向血管内注入硝酸甘油0.2 mg。沿指引导丝送入Atlantis SR Pro冠脉超声成像导管（型号：38942）至待检血管远端，至少超过钙化病变远端10 mm以上，连接iLab-IVUS检测仪。然后应用自动回撤装置以恒速（0.5 mm/s）从血管远端缓慢回撤至待检血管的近端即终止，同时应用集翔多维11.0.软件对图像数据进行分析。靶病变预处理前检测：内膜钙化弧度、钙化病变长度、参考血管直径、最小管腔直径、参照管腔横截面积、最小管腔横截面积。计算：管腔横截面积狭窄程度=（参照管腔横截面积-最小管腔横截面积）/参照管腔横截面积×100%；PCI后检测：最小支架内管腔直径、最小支架内管腔横截面积。计算：即刻管腔直径获得=术后最小支架内管腔直径-术前最小管腔直径；即刻管腔横截面积获得=术后最小支架内管腔横截面积-术前最小管腔横截面积。
1.3.2. 研究终点及术后随访
记录术中并发症，包括房室传导阻滞、严重心动过缓、低血压、冠状动脉夹层、支架贴壁不良、慢血流/无复流、分支闭塞、血管穿孔/心脏填塞等；记录术后12及24月的的临床主要不良心脏事件（MACE），包括新发严重心律失常、再发心绞痛、再发心力衰竭、靶血管再次血运重建、支架内血栓形成/再狭窄、非致死性心肌梗死、心源性死亡。再狭窄：术后随访期间血管发生狭窄，管腔局部残余程度≥20%。
1.4. 统计学分析
采用SPSS 22.0统计软件进行数据处理，计量资料以均数±标准差表示，正态分布方差齐的组间计量资料比较采用t检验，偏态计量资料采用非参数MannWhitney U检验；计数资料以频数或百分率表示，组间非等级资料比较采用χ2检验或Fisher确切概率法，均采用双侧检验，以P < 0.05为差异有统计学意义。
2. 结果
2.1. 基线资料
两组患者的基线资料及旋磨程度比较，差异无统计学意义，具有可比性（P>0.05，表 1）。
1.
两组患者基线资料及旋磨程度的比较
Comparison of baseline data and spiral grinding degree between the two groups
| Items | SB group (60 cases) | CB group (60 cases) | χ2/t | P |
| Male [n (%)] | 41 (68.3) | 38 (63.3) | 0.333 | 0.564 |
| Ages（Mean±SD, year） | 71.7±9.3 | 70.8±8.3 | 0.591 | 0.556 |
| Body mass index（Mean±SD, kg/m2） | 26.1±3.0 | 26.9±4.6 | -1.213 | 0.228 |
| Risk factors [n (%)] | ||||
| Diabetes mellitus | 20 (33.3) | 22 (36.7) | 0.147 | 0.702 |
| Hyperlipidemia | 35 (58.3) | 31 (51.7) | 0.539 | 0.463 |
| Hypertension | 23 (38.3) | 27 (45.0) | 0.549 | 0.459 |
| Smoking | 31 (51.7) | 28 (46.7) | 0.300 | 0.584 |
| Chronic kidney disease | 5 (8.3) | 8 (13.3) | 0.776 | 0.378 |
| Medical history | ||||
| Old myocardial infarction | 4 (6.7) | 7 (11.7) | 0.901 | 0.343 |
| Percutaneous coronary intervention | 5 (8.3) | 3 (5.0) | Fisher | 0.717 |
| Coronary artery bypass grafting | 0 | 1 (1.7) | Fisher | 1.000 |
| Lesion location [n (%)] | ||||
| Left anterior descending coronary artery | 34 (56.7) | 31 (51.7) | 0.302 | 0.583 |
| Left main coronary artery | 5 (8.3) | 7 (11.7) | 0.370 | 0.543 |
| Left circumflex artery | 4 (6.7) | 3 (5.0) | Fisher | 1.000 |
| Right coronary artery | 17 (28.3) | 19 (31.7) | 0.159 | 0.690 |
| Bifurcation lesion [n (%)] | 21 (35.0) | 25 (41.7) | 0.564 | 0.453 |
| Ostial lesion [n (%)] | 9 (15.3) | 7 (11.7) | 0.288 | 0.591 |
| Grinding-head diameter (mm, Mean±SD) | 1.49±0.10 | 1.48±0.11 | 0.218 | 0.828 |
| Grinding-head/Reference blood vessels diameter ratio (mm, Mean±SD) | 0.55±0.12 | 0.54±0.10 | 0.585 | 0.560 |
| Left ventricle ejection fraction (Mean±SD, %) | 53.3±5.1 | 51.5±6.0 | 1.775 | 0.078 |
| Cardiac troponin T (Mean±SD, ng/L) | 109.8±14.2 | 110.5±10.6 | -0.313 | 0.755 |
| Creatine kinase MB (Mean±SD, U/L) | 12.2±4.3 | 13.6±5.6 | -1.567 | 0.120 |
2.2. 手术即刻成功率
SB组60例中，旋磨成功60例，其中SB扩张后手术即刻成功52例，8例因SB扩张后失败，支架仍通过困难未能完成PCI，又改用CB扩张后完成PCI，SB组手术即刻成功52例（86.7%）；CB组60例中，旋磨成功59例，其中1例因旋磨中出现冠状动脉夹层而未能再行CB扩张，直接置入支架后夹层消失，CB组手术即刻成功59例（95.2%）。CB组患者的手术即刻成功率高于SB组（P=0.032）。
2.3. IVUS检测结果
PCI前两组患者的IVUS检测指标（内膜钙化弧度、参考血管直径、最小管腔直径、最小管腔横截面积、管腔横截面积狭窄程度）及PCI应用支架情况（支架置入数/ 靶血管、支架总长/靶血管）等指标比较（均P＞0.05），差异均无统计学意义，具有可比性。预处理及支架置入后，CB组患者的最小支架内管腔直径（P=0.035）、最小支架内管腔横截面积（P=0.029）、即刻管腔直径获得、即刻管腔横截面积获得及病变残余狭窄 < 10 %的优良率均明显大于SB组（P＜0.001），CB组患者的管腔横截面积残余狭窄程度轻于SB组（χ2=7.859，P=0.005），差异有统计学意义（表 2）。
2.
两组患者PCI前后IVUS检测结果比较
Comparison of IVUS results between the two groups before and after PCI (Mean±SD)
| Items | SB group (n=52) | CB group (n=59) | t | P |
| IVUS test before PCI | ||||
| Intimal calcification radian (°) | 319.1±14.3 | 319.9±16.1 | -0.288 | 0.774 |
| Calcified lesion total length (mm) | 14.16±4.06 | 15.09±3.42 | -1.304 | 0.195 |
| Reference vessel diameter (mm) | 2.79±0.37 | 2.70±0.47 | 1.136 | 0.259 |
| Minimum lumen diameter (mm) | 1.00±0.17 | 0.99±0.15 | 0.579 | 0.564 |
| Minimum lumen cross-sectional area (mm2) | 1.01±0.12 | 0.97±0.16 | 1.499 | 0.137 |
| Lumen cross-sectional area stenosis degree (%) | 83.7±3.7 | 84.9±3.9 | -1.699 | 0.092 |
| PCI stent application | ||||
| Number of stents placed/Target blood vessels (number) | 1.85±0.36 | 1.76±0.43 | 1.108 | 0.270 |
| Stent length/Target blood vessels (mm/single) | 37.2±4.3 | 35.9±3.8 | 1.605 | 0.111 |
| IVUS test after PCI | ||||
| Minimum stent lumen diameter (mm) | 2.52±0.41 | 2.66±0.30 | -2.140 | 0.035 |
| Minimum lumen cross-sectional area in the stent (mm) | 5.35±0.60 | 5.63±0.72 | -2.207 | 0.029 |
| Residual stenosis of lumen cross-sectional area (%) | 13.4±2.1 | 11.7±2.3 | 3.996 | 0.000 |
| Immediate lumen diameter acquisition (mm) | 1.40±0.30 | 1.60±0.26 | -3.873 | 0.000 |
| Immediate lumen cross-sectional area acquisition (mm2) | 3.78±0.62 | 4.80±0.53 | -9.286 | 0.000 |
| Lesions residual stenosis < 10 % [n (%)] | 3（5.8） | 15（25.4） | 7.859 | 0.005 |
2.4. 术中并发症及术后24月MACEs
CB组患者的术中并发症发生率（χ2=5.997，P=0.014）及术后24月MACE发生率均明显低于SB组（χ2=4.285，P=0.038），差异有统计学意义。两组患者术中出现并发症经用药治疗后多可好转，均未出现严重并发症（表 3）。
3.
两组患者术中并发症及术后24月MACEs比较
Comparison of intraoperative complications and MACEs within 24 months after operation between the two groups [n (%)]
| Items | SB group (n=52) | CB group (n=59) | χ2 | P |
| Note: MACEs, major adverse cardiovascular events. | ||||
| Intraoperative complications | 9 (17.3) | 2 (3.4) | 5.997 | 0.014 |
| Atrioventricular block | 1 | 1 | ||
| Severe bradycardia | 0 | 1 | ||
| Low blood pressure | 1 | 0 | ||
| Coronary artery dissection | 2 | 0 | ||
| Incomplete stent apposition | 2 | 0 | ||
| Slow flow/no reflow | 2 | 0 | ||
| Branch occlusion | 1 | 0 | ||
| Blood vessels perforation/Cardiac tamponade | 0 | 0 | ||
| MACEs 12 months after surgery | 7 (13.5) | 4 (6.8) | 1.382 | 0.240 |
| New severe arrhythmia | 2 | 2 | ||
| Recurrence angina pectoris | 2 | 1 | ||
| Recurrence heart failure | 1 | 1 | ||
| Repeat vascular reconstruction | 1 | 0 | ||
| Stent thrombosis /restenosis | 1 | 0 | ||
| Nonfatal myocardial infarction | 0 | 0 | ||
| Cardiogenic death | 0 | 0 | ||
| MACEs 24 months after surgery | 13 (25.0) | 6 (10.2) | 4.285 | 0.038 |
| New severe arrhythmia | 2 | 3 | ||
| Recurrence angina pectoris | 3 | 2 | ||
| Recurrence heart failure | 2 | 1 | ||
| Repeat vascular reconstruction | 2 | 0 | ||
| Stent thrombosis/restenosis | 2 | 0 | ||
| Nonfatal myocardial infarction | 1 | 0 | ||
| Cardiogenic death | 1 | 0 | ||
3. 讨论
IVUS的分辨率100 μm，穿透深度4~8 mm，通过超声波反射形成血管长轴及横断面影像，比冠状动脉造影更能直接显示血管腔及管壁的形态结构，更实时观察冠脉内钙化斑块范围及程度，测量钙化弧度和轴线长度，并可区分浅表钙化、深层钙化以及钙化结节。弥补冠状动脉造影的不足，诊断钙化斑块诊断的敏感度为90%，特异性为100%，为目前检测冠状动脉钙化的“金标准” [14]。同时IVUS还可为PCI术的治疗策略选择提供重要的指导意见，对于IVUS显示的Ⅲ~Ⅳ级严重钙化斑块不建议直接应用CB，应该先进行RA。因为应用CB时最大扩张压力不应超过12 atm，超高的压力引起刀片嵌顿而难以收回。另外对于无保护的左主干病变、弥漫性病变（长度>20 mm）、小血管（直径 < 2 mm）、高度成角及极度扭曲血管的病变等也应该慎用CB [15]。因此，本文中入选患者均为冠脉内Ⅳ级钙化病变，均先进行了RA治疗。
RA利用头端镶有2000~3000颗微钻石的橄榄形磨头在重度钙化处管腔内高速旋转，最高可达200 000 r/min，可“差异切割”式地打磨消融钙化组织，选择性地祛除钙化斑块，扩大管腔[16-17]。因为正常冠状动脉血管组织富有弹性，旋磨头高速旋转着通过时会被自动弹开，即正常的血管壁不会被旋磨损伤[18]。坚硬的钙化组织被研磨成直径 < 5 μm微粒（小于红细胞直径），之后被吞噬系统吞噬清理[19]。然而，在临床实践中发现RA还存在一定的不足。旋磨术开始应用的时候，倾向选择较大的旋磨头，比如旋磨头/靶血管内径比值>0.8，容易造成血管壁的损伤，引起内膜撕裂、穿孔、夹层、血管痉挛、急性闭塞、无复流及等旋磨头嵌顿[11]。随着旋磨术经验的积累，发现选择旋磨头/靶血管内径比值在0.5~0.6较为安全适宜，可避免上述风险[20]。终于体会到RA的最佳作用就是打磨修饰钙化斑块，使突出于管腔内膜粗糙的钙化硬结只是变得光滑[21]，而不是单纯利用RA扩大管腔，也就是说不能单纯依靠RA打磨掉很厚的钙化斑块。RA仅能裂解浅层钙化组织，RA术后钙化环可能会发生微小的裂隙，不会出现很深的断裂[22, 23]。如果RA术后直接置入支架很难获得理想的支架贴壁和膨胀度。因此，欲想充分有效的裂解较厚的浅表钙化环，须要联合使用多种器械进行靶血管预处理[24, 25]。
支架置入前IVUS的检测结果显示两组患者病变血管IVUS检测指标及PCI应用支架情况等指标比较差异均无统计学意义，说明两组患者基线资料均衡可比。靶血管经预处理及支架置入后，比较两组患者的IVUS结果发现，CB组患者的最小支架内管腔直径、最小支架内管腔横截面积、即刻管腔直径获得、即刻管腔横截面积获得更大，病变残余狭窄 < 10%的优良率更高，管腔横截面积残余狭窄程度更轻，提示RA+CB预处理重度钙化狭窄病变管腔获得疗效更佳，明显优于RA+SB。这与李其勇等[6]的研究结果一致，两者均采用随机对照研究，均应用IVUS检测病变靶血管。但本研究较李其勇等的研究扩大了样本含量（32例扩大至120例），延长了随访时间（术后12月延长至24月），提高了统计学效能及可信度。李其勇等[6]的研究显示两组患者术后随访时MACE发生率并无显著差异，可能与他们样本量太小和随访时间较短有关。本研究显示CB组患者的术中并发症发生率及术后24月MACE发生率较SB组降低，这是扩大样本量和延长随访时间方能观察到的结果。SB组患者术中并发症有冠状动脉夹层2例、支架贴壁不良2例、慢血流/无复流2例，而CB组没有上述术中并发症，说明RA+CB预处理更安全有效，同时也提示最小管腔面积与支架膨胀不良与支架血栓及远期支架再狭窄密切相关[25, 26]。
SB组中8例因SB扩张后未能完成PCI，又改用CB扩张后完成PCI。CB组的手术即刻成功率高于SB组，说明在旋磨术后进行CB比SB扩张更有效。因为CB表面附带着3~4组0.2~0.3 mm微型刀片非常锋利，CB充气膨胀时刀片暴露出来，利用CB扩张时自身侧向的挤压力纵行切入、裂解钙化环，可更好地避免较厚钙化斑块严重撕裂造成夹层以及管腔弹性回缩，达到更佳的预处理效果[15]。而SB扩张时并不能纵行裂解钙化环，其实就是钝性撕裂，容易造成血管夹层及壁内血肿，且SB退出后往往发生管腔弹性回缩，导致部分病例不能顺利植入支架，降低了即刻PCI成功率。但是，对于重度钙化病变单独应用CB修饰斑块也行不通。一是CB与普通球囊相比外径更大，可缩性更差，常不能顺利通过重度狭窄的钙化病变[27, 28]；二是CB不能移除冠脉钙化斑块；三是如果对于钙化结节不先旋磨，而是直接使用CB可能会导致刀片嵌顿而难以收回[29]。而RA恰恰能弥补CB的上述不足。因此，只能先应用RA打磨光滑钙化斑块环，再应用CB更充分裂解钙化斑块环。利用两种器械不同的构造特点和工作原理联合一起使用，方能扬长避短，协同发挥作用，达到理想的预处理效果。
综上所述，CB与SB的钝性、无序扩张相比，CB预处理减少血管壁弹性回缩，获得更大的绝对管腔面积，可明显提高支架置入成功率，提高支架的释放质量，达到理想的支架贴壁和展开效果，从而降低支架内血栓发生率和再狭窄率。因此，建议对于那些球囊不能通过或者支架植入前扩张不充分的重度钙化病变，建议首选RA+CB方案进行预处理。
Biography
韩风杰，主治医师，E-mail: 27420765@qq.com
Contributor Information
韩 风杰 (Fengjie HAN), Email: 27420765@qq.com.
郑 海军 (Haijun ZHENG), Email: zhenghaijunjz@163.com.
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